Medical Perspectives

Western Summary

Eczema, also known as atopic dermatitis, is a common, chronic condition of the skin that affects many children and adults.[1] Eczema is considered to result from the combination of a genetic predisposition to a defective skin barrier and an increased inflammatory response. Patients with a personal or family history of asthma, hay fever, allergies or eczema are predisposed to developing eczema. Yet there is more to eczema than just genetics. With proper care of the skin barrier, some patients can avoid eczema altogether. Controlling the inflammation produced in eczema is key as is providing the skin with hydration and minimizing exposure to triggers. The treatment of eczema is a balance between controlling bouts of inflammation and flares and maintenance therapy to keep the eczema from flaring.

Treatment Philosophy

Eczema treatment revolves around limiting inflammation and maintaining skin hydration. Prevention of eczema flares begins with limiting exposure to drying agents like soaps and fragrance-containing products, while maximizing exposure to moisturizing agents to lock in the natural and added moisture within the skin. Avoiding allergens and irritants will also help to decrease the likelihood of flares. When flares occur, anti-inflammatory medications will decrease the active inflammation and allow the skin to heal itself. As long as the skin barrier is maintained and retains its moisture, inflammation is less likely to occur and patients are more likely to remain symptom free.

Symptoms

Eczema is characterized by chronically dry, itchy and scaly skin. When scratched and irritated the skin can become red, itchy, and swollen with oozing and weeping. The skin of the cheeks, wrists, inner elbows and knees are most commonly affected in babies and young children. In older children and adults, the skin of the neck, inner elbows and the backside of the knees are affected more commonly. Eczema tends to be worse in childhood with improvement in adolescence and adult years. However, in some cases eczema can persist into adulthood.

Causes

Eczema, also called atopic dermatitis, is a chronic inflammatory skin condition. Normally the skin works as a protective barrier; in skin affected by eczema the barrier is deficient, compromising its effectiveness. This makes it easier for dryness and irritation to set in. The immune system is also overactive in people with eczema leading to the frequent signs of redness and swelling. Research has shown that people with eczema produce less antibiotic substances on the skin,[2] which may explain why there is an increased risk for skin infections.

The development of eczema is typically based on four different factors that include:

Genetic susceptibility: Eczema is an inherited disease and is commonly found in families.

Immune dysfunction: The immune system plays a role in the development of eczema,[3] and frequent bouts of exposure to irritating chemicals can worsen eczema.

Epidermal barrier dysfunction: A mutation in a gene that controls barrier function causes people to have a predisposition to the development of eczema and other “atopic” conditions, such hay fever and asthma.[4]

The population of bacteria on the skin, known as the microbiome, appears to be important in those with eczema. While everyone has bacteria on their skin, people with eczema appear to have an unhealthy population that is dominated by the bacteria Staphylococcus aureus.[5] Studies are currently underway to understand how the microbiome can be switched to a more healthy state in hopes that this can improve control of eczema.

Risk Factors

Your body

Age: Although eczema is found in almost any age group, it is more common in children.[6]

Genetics: Research shows that there is a genetic component to the development of eczema.[7] People with eczema have an abnormal protein in their skin barrier, leading to a disruption in skin function. This protein, known as filaggrin, is normally a part of a healthy skin barrier. Breakdown products of filaggrin form what is known as the natural moisturizing factor, which keeps skin hydrated.[8,9] Studies have estimated that the number of people with eczema that have an abnormal filaggrin protein may be as low as 25% to as high as 50%.[10]

Environment

Climate: Cold and dry environments may aggravate eczema. Cold temperatures worsen the function of the skin barrier.[11] An international study found that colder temperatures were associated with a greater incidence of eczema.[12] The same study showed that there was less eczema present as indoor humidity increased.[12] Additional studies have found that cold and dry climates are associated with greater prevalence of eczema.[13,14] Dry climates further dry out the skin, leading to worsening of eczema lesions. On the other hand, excessively humid and rainy weather leads to greater dampness on the skin. Evidence suggests that both very dry and very wet climates are associated with more severe eczema.[14]

Allergens: Allergens that cause a general allergic reaction of the skin can worsen eczema by causing frequent bouts of skin irritation, known as contact dermatitis or irritant dermatitis. Common environmental causes of contact dermatitis include dust mites, cat dander, animal saliva and latex.[15] Particulate air pollution has been shown to worsen the epidermal barrier function.[16]

Lifestyle

Smoking: The harmful effects of smoking are well-known, but many who suffer from eczema may not realize that it can worsen their symptoms, and the symptoms of those around them. Smoking can increase the risk of hand eczema,[17] and exposure to environmental tobacco smoke at home can increase the risk of eczema in school children.[18]

Treatments

Eczema is a chronic condition with no permanent cure. Regardless of whether a western or an alternative medical approach is implemented, it requires constant attention and care. The typical treatment for eczema has two goals:

To improve the skin barrier.

Reduce inflammation in the skin.

Medications

Anti-Inflammatory Medications: A physician may prescribe prescription-strength medications, such as steroids or calcineurin inhibitors, for reducing inflammation in the skin. This is a temporary means to help the skin heal faster. These medications will decrease the current inflammation in the lesion, allowing the skin to rebuild its protective barrier.

Topical steroids are a common class of medications for eczema and work by suppressing the immune responses of the skin. While quite effective in treating the condition, up to 20% of patients are not satisfactorily treated with topical steroids[19] and may require additional treatments. Topical calcineurin inhibitors are another class of anti-inflammatory agents prescribed as an alternative to topical steroids.

Oral anti-inflammatory and immune suppressing medications are used in more severe cases. Some examples include cyclosporine, azathioprine and systemic steroids.

Newer medications are emerging that suppress specific aspects of the immune response to help decrease the inflammation seen in severe eczema. These medications, like dupilumab, require regular injections into the skin.

Antibiotics: If there are any signs of secondary infection (such as swelling, redness, pus, and pain) antibiotics may be prescribed to reduce inflammation and treat the infection. The bacteria aureus tends to overgrow in people with eczema and antibiotics are directed toward controlling its overgrowth.

Products

Moisturizers: The use of a skin cream/moisturizer is important in bolstering the skin barrier and in maintaining hydration. These should be applied daily and after bathing, especially if soap was used. There are many different kinds of moisturizers available and these should be carefully selected. For example, some moisturizers are much heavier due to an ointment base while others may be lighter due to a cream or lotion base.

Soap: Due to the deficient barrier seen in eczema, eczema skin is more sensitive to products that have the ability to be irritating and drying. Soaps can both irritate and dry the skin, and should be used judiciously in those with eczema. In particular, the arms and legs are more sensitive to the potential negative effects of soap as they tend to make natural oils less than the face, chest, and back. Research has shown that totally avoiding soap is not healthy either. One study conducted with 130 eczema sufferers who did not use any soap for 30 days showed that restarting soap use while bathing was helpful to their eczema if a moisturizer was used immediately after bathing.[20] Overall, soap can be irritating to the skin but should be used once in a while, immediately followed by the use of a moisturizer after bathing.

Fragrance-containing products: Fragrances are found in many creams and lotions. These chemicals can be irritating in general,[21] and particularly in people with eczema.[22] However, buying fragrance-free does not mean that a skin product does not have any fragrance. Many fragrances can be used in a product if they have another function, such as the fragrance benzyl alcohol that also acts as a preservative. This is an important caveat to remember when evaluating products that claim to be “fragrance free.”

Nutrition & diet

Diet: Dietary changes will depend on each individual patient, but can make an impact in some patients. Some patients have food sensitivities and may benefit from eliminating food groups that are related to eczema flares. Food allergies should be evaluated by a healthcare professional, but also play a role in eczema flares. A study in Denmark showed that carefully planned elimination diets were helpful in 39% of the 675 people that participated in the study.[23] The study also found that there was long term improvement over 1-3 years in 70% of those that continued in the long-term follow up study.[23] Elimination diets should be done carefully as elimination diets can lead to poor nutrition in both children and adults. They should be done under the direction of a health professional.

Supplements

Vitamin D: Although vitamin D’s role in the treatment of eczema is debated, patients with a history of eczema often have reduced vitamin D levels,[24] while eczema has improved with vitamin D supplementation.[25]

Glutamine: In a study of low birth weight infants supplemented with the amino acid glutamine, it was shown that the infants who received glutamine had lower rates of developing eczema.[26] Similar results have been shown in mouse models.[27]

Lifestyle changes

Dilute bleach baths: Dilute bleach baths help to control the overgrowth of the aureus bacteria on the skin when used consistently twice weekly over 3 months.[28] The nose can harbor S. aureus and bleach bath studies have found that application of the an antibiotic ointment (mupirocin ointment) into the nose along with the bleach baths was effective in reducing S. aureus on the skin.[28] Dilute bleach baths are similar to taking a dip in a swimming pool and have been shown to be safe on the skin.[29]

Reduce soap use: Reducing soap use can help with maintaining the hydration of the skin. Soaps may still need to be used in areas that are moist and oily (such as the armpits and groin), but people with eczema may improve with reduced soap use to the body, arms and legs. If soap is absolutely necessary, products that contain sodium lauryl sulfate should be avoided at the very least.[30]

Stop Smoking & Limit Second-hand smoke exposure: Second-hand smoke can aggravate eczema. Reducing smoking, or smoking cessation altogether, can lead to a decrease in allergic responses of those exposed to second-hand smoke.[31,32]